Provider Demographics
NPI:1700973658
Name:GULLEY, R. BRYAN (DDS)
Entity Type:Individual
Prefix:
First Name:R.
Middle Name:BRYAN
Last Name:GULLEY
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6421 SARATOGA BLVD
Mailing Address - Street 2:101
Mailing Address - City:CRP CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78414-3479
Mailing Address - Country:US
Mailing Address - Phone:361-992-3873
Mailing Address - Fax:361-992-7328
Practice Address - Street 1:6421 SARATOGA BLVD
Practice Address - Street 2:101
Practice Address - City:CRP CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78414-3479
Practice Address - Country:US
Practice Address - Phone:361-992-3873
Practice Address - Fax:361-992-7328
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX120101223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0902611-02Medicaid
TXD12010Medicare PIN
TXT13595Medicare UPIN